Anticoagulant Use during Subacute Asymptomatic Cerebral Cavernous Malformation Hemorrhage

Several cohort analyses and 2 meta-analyses show a lower risk of cerebral cavernous malformation (CCM) hemorrhage in patients taking anti-thrombotics than those without. Most of the reported patients were taking antiplatelet agents rather than anticoagulants, and little is reported on the use of anticoagulation in the setting of an acute CCM hemorrhage.

We present 3 patients from our practice requiring anticoagulation in the setting of CCM hemorrhage. Patient 1 (age: 61 years) was hospitalized with headache and right arm and leg numbness after a COVID-like illness. Imaging demonstrated a right frontal CCM with subacute blood products in addition to sagittal and transverse sinus thrombosis. The patient was initiated on IV heparin and transitioned to Eliquis. While the CCM continued to have bright T1 signal, it did not result in symptoms over the 12 months of anticoagulation. Patient 2 (age: 62 years) had a history of recurrent pulmonary embolism (PE) on apixaban and underwent brain MRI as part of a metastatic work up for cancer. MRI demonstrated a medullary CCM with subacute blood products. Due to high risk of PE recurrence, anticoagulation maintained and subsequent follow-up MRIs over 1 year were stable and the patient remained asymptomatic. Patient 3 (age: 16 years) was admitted for headache and vomiting, found to have hydrocephalus, an unusual diffuse CCM with subacute blood products and initial concern for occlusion of the straight sinus. He was placed on IV heparin for possible sinus thrombosis with clinical and radiographic stability of his hemorrhages. After a ventricular drain was placed, the straight sinus resumed normal size and the original presentation thought to be pseudo-occlusion due to high pressure.

The lack of symptoms and radiographic worsening in these 3 CCM patients acutely anticoagulated with presence of subacute CCM blood products supports the theory that CCM hemorrhage may relate to intra-cavernous thrombosis.